MolecularphenotypesofhumanparvovirusB19inpatientswithmyocarditis Bock CT,Düchting A,Utta F,Brunner E,Sy BT,Klingel K,Lang F,Gawaz M,Felix SB,

AIM: To investigate molecular phenotypes of myocardial B19V-infection to determine the role of B19V in myocarditis and dilated cardiomyopathy (DCM).METHODS: Endomyocardial biopsies (EMBs) from 498 B19V-positive patients with myocarditis and DCM were analyzed using molecular methods and functional experiments. EMBs were obtained from the University Hospitals of Greifswald and Tuebingen and additionally from 36 German cardiology centers. Control tissues were obtained at autopsy from 34 victims of accidents, crime or suicide. Identification of mononuclear cell infiltrates in EMBs was performed using immunohistological staining. Anti-B19V-IgM and anti-B19V-IgG were analyzed by enzyme-linked immunosorbent assay (ELISA). B19V viral loads were determined using in-house quantitative real-time polymerase chain reaction (PCR). For B19V-genotyping a new B19V-genotype-specific restriction fragment length polymorphism (RFLP)-PCR was established. B19V-genotyping was verified by direct DNA-sequencing and sequences were aligned using BLAST and BioEdit software. B19V P6-promoter and HHV6-U94-transactivator constructs were generated for cell culture experiments. Transfection experiments were conducted using human endothelial cells 1. Luciferase reporter assays were performed to determine B19V-replication activity. Statistical analysis and graphical representation were calculated using SPSS and Prism5 software.RESULTS: The prevalence of B19V was significantly more likely to be associated with inflammatory cardiomyopathy (iCMP) compared to uninflamed DCM (59.6% vs 35.3%) (P < 0.0001). The detection of B19V-mRNA replication intermediates proved that replication of B19V was present. RFLP-PCR assays showed that B19V-genotype 1 (57.4%) and B19V-genotype 2 (36.7%) were the most prevalent viral genotypes. B19V-genotype 2 was observed more frequently in EMBs with iCMP (65.0%) compared to DCM (35%) (P = 0.049). Although there was no significant difference in gender-specific B19V-loads, women were more frequently infected with B19V-genotype 2 (44.6%) than men (36.0%) (P = 0.0448). Coinfection with B19V and other cardiotropic viruses was found in 19.2% of tissue samples and was associated with higher B19V viral load compared to B19V-monoinfected tissue (P = 0.0012). The most frequent coinfecting virus was human herpes virus 6 (HHV6, 16.5%). B19V-coinfection with HHV6 showed higher B19V-loads compared to B19V-monoinfected EMBs (P = 0.0033), suggesting that HHV6 had transactivated B19V. In vitro experiments confirmed a 2.4-fold increased B19V P6-promoter activity by the HHV6 U94-transactivator.CONCLUSION: The finding of significantly increased B19V loads in patients with histologically proven cardiac inflammation suggests a crucial role of B19V-genotypes and reactivation of B19V-infection by HHV6-coinfection in B19V-associated iCMP. Our findings suggest that B19V-infection of the human heart can be a causative event for the development of an endothelial cell-mediated inflammatory disease and that this is related to both viral load and genotype.     

Anasarca as the presenting manifestation of parvovirus B19 associated juvenile dermatomyositis

Anasarca as the presenting manifestation of juvenile dermatomyositis (JDMS) is extremely rare. We report a case of a 4-year-old boy who was initially managed for nephrotic syndrome in view of anasarca and mild hypoalbuminemia. Later, at presentation to our institute, a diagnosis of severe edematous JDMS was made in view of associated profound muscle weakness and characteristic skin changes. The child responded to aggressive immunosuppressive therapy. On further evaluation, he had evidence of acute parvovirus B19 infection. Our case illustrates anasarca as an uncommon severe manifestation of JDMS and the possible role of parvovirus B19 in the onset of this autoimmune disorder.     

Acute parvovirus B19 infection mimicking myelodysplastic syndrome of the bone marrow

Summary A 36-year-old, previously healthy woman was referred to our institution with pancytopenia and splenomegaly for suspected acute leukemia. Bone marrow aspiration showed marked dysplastic changes, excess of blasts, and only spurious red blood cell precursors. Action was taken to prepare allogeneic bone marrow transplantation from an HLA identical sibling for myelodysplastic syndrome. Repeat cytological examination of the bone marrow revealed striking hyperplasia of the red cell line with presence of abnormal giant proerythroblasts. Acute parvovirus B19 infection was suspected and confirmed by detection of anti-B19 IgM and B19 DNA. The underlying disease for this transient aplastic crisis was a formerly unknown hereditary spherocytosis.     

人细小病毒B19感染在心肌病发病中的作用

目的 :探讨人细小病毒B19(HPVB19)感染在心肌病发病中的作用。方法 :病理诊断确诊为炎症性心肌病患者 30例 ,扩张型心肌病 (DCM)患者 36例 ,肥厚型心肌病 (HCM)患者 13例 ,无心肌炎、DCM或近期感染者 (对照 ) 36例。所有被研究者均行心肌组织活检 ,用于病理组织学检查和巢式聚合酶链反应 (PCR)检测分析HPVB19 DNA。结果 :炎症性心肌病中有 4例HPVB19 DNA阳性 (占 13.3% ) ,DCM中有 3例HPVB19 DNA阳性 (占 8.3% ) ,HCM中有 2例HPVB19 DNA阳性 (占 15 .4 % ) ,而对照组HPVB19 DNA均为阴性。结论 :心肌病患者中HPVB19感染率较高 ,HPVB19感染可能是心肌病的重要病因之一。     

Successful Treatment with Cyclosporine and High-Dose Gamma Immunoglobulin for Persistent Parvovirus b19 Infection in a Patient with Refractory Autoimmune Hemolytic Anemia

We describe a patient with persistent pure red cell aplasia due to human parvovirus B19 (HPVB19) infection during immunosuppressive therapy for refractory autoimmune hemolytic anemia (AIHA). The patient had been given corticosteroid (CS) and/or azathioprine for AIHA. During the course of treatment, reticulocyte count and hemoglobin levels decreased suddenly. Bone marrow aspirate showed erythroid lineage-specific aplasia with a few giant proerythroblasts, suggesting the presence of HPVB19 infection. The diagnosis of aplastic crisis due to HPVB19 infection was based on positive test results by polymerase chain reaction for HPVB19 immunoglobulin M (IgM) antibody and B19 DNA. Although splenectomy followed by administration of high-dose gamma globulin (HDIG) and plasma exchange were performed, the crisis and hemolysis recurred. Aplastic crises occurred several times when the B19 IgG result became negative and the CD4+ lymphocyte count was less than 300/microL. The patient showed complete recovery from anemia after CS was switched to cyclosporin A (CsA) and intermittent administration of HDIG. The result for B19 IgG antibody was continuously positive, and the DNA result became negative after these treatments. The results in this case indicated that concomitant administration of CsA and intermittent administration of HDIG can lead to cure of chronic anemia due to HPVB19 infection in patients with refractory AIHA.     

Multiple small pulmonary emboli associated with transient antiphospholipid syndrome in human Parvovirus B19 infection

Antiphospholipid antibodies (aPL) have been reported to occur in several conditions other than antiphospholipid syndrome, including infections. We herein report the case of a 21-year-old Japanese woman with Parvovirus B19 infection, who developed multiple pulmonary emboli associated with aPL, a lupus anticoagulant and IgM anticardiolipin antibody. Eight weeks later, antiphospholipid antibodies spontaneously disappeared and normal pulmonary flow was observed. Considering the high prevalence of Parvovirus B19 infection, we should be aware of thrombosis associated with transient aPL antibodies in this infectious disease.     

Outcome of patients with arthritis and parvovirus B19 DNA in synovial membranes

To investigate the follow-up of the 17 patients during the period of 1995–2001 of the outpatient Clinic for Rheumatology at the University Hospital of Zurich with arthritis and the presence of parvovirus B19 DNA demonstrated by PCR in synovial biopsies. Seventeen patients of 163 with arthritis, which were routinely examined by needle arthroscopy during 1995–2001 with a positive parvovirus B19 DNA by PCR of synovial biopsy were reevaluated. Investigations included medical history, clinical examination and blood tests. Joint fluid was taken on patients with joint effusion. The observation period of the 17 patients (F:M = 11:6) was 2–8 years (Ø = 6.5 years). In 8 of 17 patients the arthritis could not be classified neither at entry nor during the follow up of the study. The arthritis could be diagnosed in six patients early in the onset of the disease and included three cases of lyme arthritis of the knee joint, two cases with arthritis following a gastrointestinal infection (one with Salmonella typhimurium—positive faecal test—and the other one with a culture negative agent), one patient probably had an infection-associated arthritis after a gastrointestinal infection with Entamöeba histolytica (Schirmer et al. in Rheumatol Int 18:37–38, 1998; Kasliwal in Am J Proctol Gastroenterol Colon Rectal Surg 32:12, 16, 28, 1981; Haslock and Wright in J R Coll Phys Lond 8:1554–162, 1974; Than-Saw et al. in Trop Geogr Med 44:355–358, 1992) with remission after antibiotic therapy. After a disease course of 9 months one patient could be classified as rheumatoid arthritis in the presence of anti-cyclic citrullinated antibodies but lack of rheumatoid factor. One patient with polyarthritis developed psoriasis of the skin 22 months later. From the nine patients with unclassified arthritis 4 (45%) got into complete remission with no symptoms or signs of joint inflammation after a disease course of 9–45 months, whereas 5 (55%) still demonstrate active non erosive arthritis (disease duration between 3 and 10 years). The presence of parvovirus B19 DNA in synovial tissue of patients with joint inflammation does not allow the diagnosis of parvovirus induced arthritis. If the arthritis remains unclassified and without erosions over time a virus associated aetiology may be assumed. However, no definitive diagnosis is possible even in the presence of parvovirus B19 DNA in synovial tissue.     

Seroprevalence of parvovirus B19 in fibromyalgia syndrome

This study was aimed to evaluate the seroprevalence of parvovirus B19 in patients with fibromyalgia syndrome (FS). Seventy-five patients with FS (44.3 ± 8.3) and 75 healthy controls (44.2 ± 8.1) were evaluated. Serum anti-B19 IgM and IgG antibodies were measured by ELISA technique. Patients were questioned about duration of symptoms, characteristic features of FS, and symptoms related with viral infection preceding the onset of FS. No significant difference was found regarding the prevalence of anti-B19 IgM antibodies between the groups (p = 0.494). Seropositivity of anti-B19 IgG of the patients was significantly higher than control group (81.3% vs. 64% respectively, p = 0.027). No statistically significant differences were found regarding to the clinical features between fibromyalgia patients with IgG antibody compared to those without IgG antibody. Parvovirus B19 IgG seropositivity was found to be significantly higher in patients with FS. Parvovirus B19 infection might have a role in the etiopathogenesis of FS or might act as a triggering factor.     

Parvovirus B19-related chronic monoarthritis: immunohistochemical detection of virus-positive lymphocytes within the synovial tissue compartment: Two reported cases

Apart from systemic symptoms of viral infection parvovirus B19, the infectious agent in erythema infectiosum, can lead to mainly self-limited acute and chronic arthropathy. Because mild subclinical features of the disease can be easily overlooked, joint affections might appear as isolated symptoms. We here report two cases of chronic monoarthritic symptoms of unknown origin, where immunohistochemical detection of B19-positive lymphocytic cells in the synovial tissue led to the diagnosis of B19 arthropathy. In conclusion, respective virus diagnostics should be considered even in chronic monosymptomatic arthritic lesions. The pathology of B19 arthropathy seems to be due to direct virus infection of cells within the synovia.     

Different patterns of disease manifestations of parvovirus B19-associated reactive juvenile arthritis and the induction of antiphospholipid-antibodies

Children with rheumatic oligo- and polyarthritis frequently establish persistent parvovirus B19 infections, which may be associated with the production of antiphospholipid antibodies. Reported in this paper are the data of five girls with polyarticular rheumatic diseases of different types and persistent parvovirus B19 infection associated in four cases with the presence of antibodies against phospholipids. Clinical parameters, virus load, and antiphospholipid-IgG levels were determined during an observation period up to 92 months. In two patients, erythema infectiosum preceded the development of arthritis and B19 viremia persisted. Two other girls showed antibodies against parvoviral structural proteins at time of the manifestation of the rheumatic disease. Subsequent samples also revealed persistent B19 infection. In the fifth patient, parvovirus B19-specific IgG antibodies were detected for the first time after 120 months of progressing disease at an age of 11 1/2 years. Five years later, quantitative polymerase chain reaction (PCR) revealed viral DNA. In a synovial tissue specimen subsequently obtained, parvovirus B19 structural proteins could be detected by immunohistochemistry. Three of five patients recovered completely without severe sequels. One patient is in remission under immunosuppressive therapy. The fifth patient suffers from progressive erosions despite intensive therapeutical efforts. In consequence, parvovirus B 19 should generally be taken into consideration as a trigger of various forms of juvenile arthritis and persistence of infection should be evaluated.     

Parvovirus B19 associated neutropenia. Treatment with Rh G-CSF

In a 39-year-old patient under follow-up for metastatic adenocarcinoma of the colon, a post-operative fever and a profound neutropenia occurred during hospitalization. A diagnosis of primary infection with parvovirus B-19 was made in view of the association of reticulocytopenia, together with anti-B19 IgM antibodies and positive serum results for viral DNA. The granulocytic lineage appeared to be normal on bone-marrow smears, and anti PMN autoantibodies were not found. Rh G-CSF therapy resulted in a sharp increase in the PMN count. Although the pathophysiology of B19-associated neutropenia remains unclear, Rh G-CSF seems to be effective in this disorder.     

Parvovirus B19-induced multisystem disease simulating systemic vasculitis in a young child

Parvovirus B19 mostly presents as a transient viral illness or as pure red cell aplasia. However, this virus can sometimes cause an illness that may pose diagnostic difficulties. We describe one such patient who had clinical features simulating a vasculitic disorder secondary to parvovirus B19 infection.     

Successful Bone Marrow Transplantation for Severe Aplastic Anemia in a Patient with Persistent Human Parvovirus B19 Infection

Persistent infection with human parvovirus B19 (B19) is primarily associated with chronic bone marrow failure in immunocompromised patients, but occasionally this organism may also affect immunocompetent hosts. B19 is also suggested as a causative agent of organ failure during bone marrow transplantation (BMT).We herein report the case of a 9-year-old girl with no previous history of immunodeficiency who developed severe aplastic anemia concurrent with B19 persistent infection. Both immunoglobulin (Ig)M antibody to B19 and B19 DNA identified by real-time polymerase chain reaction were found in the patient's serum at time of diagnosis of aplastic anemia. No giant proerythroblasts were found in her bone marrow at diagnosis. Although intravenous administration of Ig (IVIg) reduced serum B19 DNA, the aplastic status of her bone marrow did not improve. Both aplastic anemia and persistent B19 viremia were successfully treated by BMT from an HLA-identical sibling donor. Serum B19 DNA increased temporarily after BMT; however, neither organ nor marrow failure was observed. B19 DNA disappeared from the serum 2 months after BMT, suggesting that a normal immune response was restored by BMT and terminated the B19 viremia. During BMT, use of high-titer IVIg for B19 might prevent B19-associated organ failure.     

Parvovirus B19 infection and systemic lupus erythematosus: Activation of an aberrant pathway?

Parvovirus B19 infection has been associated with a variety of rheumatic manifestations/diseases, mainly rheumatoid arthritis, vasculitis and systemic lupus erythematosus (SLE). B19 infection may simulate both clinical and laboratory features of SLE, presenting either as a potential first time diagnosis of SLE or as an exacerbation of previously established disease. The similarities in both clinical and serological features of parvovirus infection and SLE at presentation may hinder the differential diagnosis between these two conditions. Hence, parvovirus B19 infection mimicking SLE usually fulfils <4 ACR criteria for SLE, rarely includes cardiac or renal involvement or presents with haemolytic anaemia, and is usually associated with short-lived, low titers of autoantibodies. Rarely, cases of multisystemic involvement solely attributed to a recent parvovirus B19 infection have been reported, rendering early accurate diagnosis of particular importance and justifying the screening for evidence of parvovirus B19 involvement in newly diagnosed cases of SLE, especially the ones with abrupt onset of symptoms along with cases of SLE flares. This review describes basic features of parvovirus B19 structure and pathogenicity and expands on the parvo-associated auto-immune manifestations particularly in relation to SLE-mimicking or SLE-triggering reported cases. The proposed mechanisms for viral-induced pathologic autoimmunity are discussed with emphasis on emerging data regarding the aberrant expression and localization of autoantigens and their potential implication in alternatively activated immunological cascades.     

细小病毒性关节炎四例临床分析并文献复习

目的 通过对我科确诊的4例细小病毒B19（parvovimsB19）关节炎的临床特点的总结．提高对该病的认识。方法 报道4例确诊为细小病毒B19关节炎的临床及实验室检查特点．并进行文献复习。结果 4例患者（男性2例，女性2例），年龄15～55岁，发病年龄中位数为34岁。关节炎同时出现流感样症状、皮疹等表现，外周血细小病毒B19 IgM均阳性，3例患者外周血细小病毒B19DNA检测阳性，除外其他原因所致关节炎，治疗效果肯定，随访1～3年无一例复发。结论 对于某些症状不典型的关节炎，应警惕细小病毒B19关节炎的可能，及时行细小病毒B19抗体及DNA检测，以助诊断。     

Clinical and hematological study for Parvovirus b19 infection in children with acute leukemia

The role of Parvovirus B19 in acute leukemia is under debate. This study aimed to detect parvovirus B19 DNA together with its antibodies in the sera of children with recent acute leukemia and those with acute leukemia receiving chemotherapy to clarify the contribution of this infection to changes observed in hematological and clinical presentations in these populations. Two groups were included: Group I comprised 45 children with acute leukemia receiving chemotherapy and Group II comprised 40 children with recently diagnosed acute leukemia. Serum parvovirus B19 IgG and IgM were investigated by enzyme-linked immunosorbant assay and the virus DNA was sought by polymerase chain reaction assay. Viral DNA was found in 22.2% of Group I patients and in 45% of Group II patients. Hemoglobin levels were significantly reduced in patients with recent infection, accompanied by statistically significant lymphocytosis in Group I patients. Group II patients with recent infection had marked neutropenia with lymphocytosis and thrombocytopenia. There was statistically significant lymphadenopathy and hepatosplenomegaly in patients with recent infection in both groups. Parvovirus B19 infection is an important cause of cytopenia in children with acute leukemia both when recently diagnosed and receiving chemotherapy. This can affect the schedule of chemotherapy. Moreover, the presence of Parvovirus B19 is associated with marked lymphadenopathy and hepatosplenomegaly.     

Viral metagenomics performed in patients with acute febrile syndrome during Toxoplasma gondii outbreak in south Brazil

Toxoplasmosis is a zoonotic infection caused by the protozoan parasite Toxoplasma gondii. The infection is widely disseminated in the human population and is usually benign or asymptomatic. Systemic T. gondii infection presents risks for pregnant women and AIDS patients. Although rare, T. gondii can cause outbreaks in urban centers. The origin of these outbreaks is not completely understood but probably results from introduction of zoonotic T. gondii strains in the population. During such outbreaks other pathogens which mimic T. gondii acute febrile syndrome may also circulate; therefore, detailed investigation of the outbreak is of extreme importance. In this study we performed viral metagenomics next-generation sequencing (mNGS) in patient samples obtained during T. gondii outbreak in Santa Maria city, South Brazil. Specific bioinformatics pipelines specialized in virus discovery were applied in order to identify co-circulating vial agents. Epstein Barr virus and Parvovirus B19 contigs were assembled and these viruses can cause symptoms similar to toxoplasmosis. In conclusion, our findings show the importance of Metagenomics next generation sequencing (mNGS) use to help characterize the outbreak more completely and in the management of the affected patients.     

Bone marrow necrosis and fat embolism syndrome in sickle cell disease: Increased susceptibility of patients with non-SS genotypes and a possible association with human parvovirus B19 infection

Fat embolism syndrome (FES) due to extensive bone marrow necrosis (BMN) in sickle cell disease (SCD) is a potentially under-diagnosed complication associated with severe morbidity and mortality. We identified 58 cases reported in the world literature to date. Typically, patients presented with a seemingly uncomplicated vaso-occlusive crisis (VOC) and subsequently deteriorated rapidly with a drop in their haemoglobin and platelets, development of respiratory failure, encephalopathy and varying degrees of involvement of other systems. Overall mortality in the reported cases was 64% but differed according to the use of transfusion and was 29%, 61% and 91% for patients receiving exchange, top-up or no transfusion respectively. Patients most at risk appear to be those with a “milder” form of SCD as 81% of patients had a genotype other than HbSS and the majority had no history of significant sickle-related complications. Human parvovirus B19 (HPV B19) infection was documented in 24% of cases.